Henry Rosevear, MD, discusses Enhanced Recovery After Surgery, a protocol that allows urologists in the trenches to provide excellent perioperative care.
Dr. Rosevear, MDRecently my partner and I were performing a cystectomy, and as is common during most long cases, our discussion became a bit philosophical. Both of us were trained in the era of open cystectomy, but as this case was being done robotically, the conversation turned toward the future of surgical treatment of muscle-invasive bladder cancer.
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Surgical treatment of bladder cancer has a long and storied history dating back to 1852. Detubularization to create a low-pressure reservoir was a milestone by Kock in the mid-1960s, and Mitrofanoff described the trans-appendicular continent cystostomy in 1980. In 1992, the first pure laparoscopic simple cystectomy was reported, and by 2003, case series of robot-assisted cystectomy and diversion were reported. (For a more detailed account, see “Bladder cancer and diversion: A historical perspective”)
Now, completely intracorporeal robotic procedures have been reported and are common.
So where do we go from here? Unless someone is able to grow a new bladder using the patient’s own tissue, the surgical technique we have maintains good oncologic principles while providing an outcome that mimics the patient’s original bladder and can be done in a minimally invasive manner. Are we done advancing the field? Absolutely not. While the technique works, radical cystectomy still carries an unacceptably high complication rate likely secondary to a combination of patient-specific issues (patients tend to be older and sicker) and disease- and procedure- specific issues (the operation still exposes patients to major abdominal surgery combined with the metabolic changes that go along with exposing urine to the bowel).
What is the future? The future is Enhanced Recovery After Surgery, or ERAS.
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Quoting Dr. Urbach, “The immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice.” Fast-track recovery protocols were introduced in the 1990s, and I’m sure most of us had some in-house developed protocol for patients after cystectomy. The ERAS society is dedicated to standardizing perioperative care by maintaining a constantly updated, peer-reviewed, evidence based protocol which is free to access and has been shown in numerous papers to decrease the post operative morbidity of the procedure.
European Urology recently published a review of this protocol that concludes, “ERAS pathways clearly improve patient care, reduce morbidity, and shorten LOS. All studies evaluating elements of the ERAS care pathways in radical cystectomy have found benefits in postoperative morbidity, return to bowel function, or LOS.” The link here, from Clinical Nutrition, is the current ERAS protocol for perioperative care after radical cystectomy.
The beauty of this protocol is that is allows those of us in the trenches of urology who don’t work at a major academic center to provide the same excellent perioperative care, just without residents. And that is not necessarily a disadvantage!
If anyone else is transitioning their hospital to an ERAS protocol and has had either good or bad experiences with such a protocol, please write and let me know.
Even though the Ebers’ Papyrus (a collection of ancient Egyptian manuscripts dating from 2600-1200 BC found in a tomb at Thebes in 1862) describe in great detail hematuria and the presence of parasites in the bladder (schistosomiasis anyone?), the earliest cystoprostatectomy and urinary diversion didn’t happen until 1852 when J. Simon performed a ureteroproctostomy for exstrophy. The patients didn’t do very well, and it wasn’t until 1911 when Coffey modified the technique of ureteral implantation that ureterosigmoidostomy became standard. That same year, Zaayer introduced the ileal conduit and by 1950 with modifications by Bricker, ileal conduits were now standard due in no small part to the more manageable metabolic changes associated with them.
The concept of a true continent diversion was the subject of work by Tizzoni and Foggi as far back as 1888. By the turn of the century, others such as Verhoogen (1908), Makkas (1910), and Laengemann (1912) had explored the idea of using an ileocecal segment with the appendix as the continent mechanism. By the 1950s, Gilchrist and Merricks modified the procedure to use the terminal aperistaltic segment of ileum as the continent mechanism.
The concept of detubularization to create a low-pressure reservoir was introduced by Kock in the mid-1960s and led to significant improvement in results. Using these principles, new techniques combining different bowel segments with various continence mechanisms were proposed (the Koch pouch using ileum and a nipple valve for continence, the Indiana pouch using an ileocecal segment with a tapered ileal segment for continence, and finally the Mainz pouch using ileum and an intussucepted ileal nipple). Mitrofanoff described the trans-appendicular continent cystostomy in 1980 that finally allowed for an easily reproducible continence mechanism.
In the late 1980s, Studer and Hautmann described the orthotopic neobladder and after almost 150 years of work, we finally had a continent diversion that closely duplicated the original bladder. In 1992, with the advent of the laparoscopic era, the first pure laparoscopic simple cystectomy was reported and by 2003, case series of robot-assisted cystectomy and diversion were being reported. (Drs. Hautmann [Eur Urol 2006; 50:1139–50] and Studer [Probl Urol 1991; 5:197–202] provide excellent historical reviews for those interested in more details.)
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